BVA9500654 DOCKET NO. 93-11 110 ) DATE ) ) On appeal from the decision of the Department of Veterans Affairs Regional Office in No. Little Rock, Arkansas THE ISSUE Entitlement to an increased rating for schizophrenia, currently rated as 50 percent disabling. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD P. M. Lynch, Associate Counsel INTRODUCTION The veteran's active military service extended from October 1963 to June 1966. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a January 1991 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in North Little Rock, Arkansas. That rating decision continued a 50 percent rating for schizophrenia which had been in effect since January 1976. The veteran's claim for a total disability rating based on unemployability was received in January 1992. An April 1992 rating decision denied the claim and the veteran was informed of the decision in May 1992. It appears that the veteran has expressed disagreement, but this matter has not been developed for appellate consideration and is not properly before the Board at this time. It is referred to the RO for action deemed appropriate. REMAND During active service, the veteran was diagnosed as having a schizophrenic reaction, undifferentiated type. Service connection for this disability was granted in August 1966 and is currently evaluated as 50 percent disabling. The United States Court of Veterans Appeals (Court) has held that the duty to assist the veteran in obtaining available facts and evidence to support his claim includes obtaining medical records to which the veteran has referred, adequate VA examinations, records in the possession of the VA, and pertinent evidence that applies to all relevant facts. See Sanders v. Derwinski, 1 Vet.App. 88 (1990); Murphy v. Derwinski, 1 Vet.App. 78 (1990); Littke v. Derwinski, 1 Vet.App 90 (1990); and Seavey v. Derwinski, 2 Vet.App. 262 (1992). The veteran has referred to receiving treatment for his condition from private physicians and facilities throughout the appeal. The Court has held that the duty to assist includes obtaining pertinent private medical records. See Ferraro v. Derwinski, 1 Vet.App. 326 (1991). A review of the record indicates that the veteran was treated at the Mental Health Center in Texarkana, Arkansas as early as 1968, and has continued such treatment until the present time. There are no medical records from this facility currently associated with the claims folder. The veteran has also regularly received treatment from James H. Thomas, M.D. There are only two brief summaries of record from this physician. In addition, the veteran has received treatment at the VA Medical Center in Shreveport, Louisiana from April 1973 until approximately July 1992. He has also been treated at the Shreveport Mental Hygiene Clinic. A review of the record reveals that discharge summaries, and not complete treatment records, are currently associated with the claims folder. Also of record is a letter from Sharon Howard, M.A. of the Southwest Arkansas Counseling and Mental Health Center. She indicated that the veteran has received treatment on a continual basis since October 1983. No treatment records from this facility are currently associated with the claims folder. The veteran's most recent examination of record was conducted in July 1992. Given the extent of absent medical records, it is likely that the examiner was not able to render a fully informed medical opinion. The duty to assist includes a duty to develop facts when the record before the Board is clearly inadequate. The development of facts includes a "thorough and contemporaneous medical examination, one which takes into account the records of prior medical treatment, so that the evaluation of the claimed disability will be a fully informed one." Green v. Derwinski, 1 Vet.App. 121, 124 (1991). In August 1994, the RO received a comprehensive report dated in June 1991 from Ken Allen, a social worker. The RO should obtain all of Mr. Allen's pertinent records on the veteran. To ensure that VA has met its duty to assist the claimant in developing the facts pertinent to the claim and to ensure full compliance with due process requirements, the case is REMANDED to the RO for the following development: 1. The veteran should be requested to furnish a complete list with the names of all health care providers and hospitals, with addresses if available, from which he has received treatment for any type of psychiatric disorder since 1990. The Board is particularly interested in records of treatment that the veteran received at the Mental Health Center in Texarkana, Arkansas; from James H. Thomas. M.D.; at the Wadley Hospital in Texarkana, Arkansas; at the Shreveport VA Medical Center and Mental Hygiene Clinic in Louisiana; at the Southwest Arkansas Counseling and Mental Health Center in Texarkana, Arkansas; and from Ken Allen, professional social worker. 2. After obtaining the appropriate releases, the health care providers and hospitals listed by the veteran should be contacted and requested to provide complete treatment records and hospital treatment folders in their possession pertaining to the veteran. If these records are unavailable or are duplicates of those already on file, that fact should be annotated in the claims folder. Any available records should be associated with the claims folder. 3. Following the above, the veteran should be examined by a VA psychiatrist who has not previously examined him to determine the nature and extent of the service-connected psychiatric disorder. The report of examination should include a detailed account of all manifestations of psychiatric pathology found to be present. If there are different psychiatric disorders, the examiner should reconcile the diagnoses and should specify which symptoms are associated with and which disorders are part of or caused by the service-connected disorder. If certain symptomatology cannot be disassociated from one disorder or another, it should be specified. The psychiatrist should describe how the symptoms of the service-connected psychiatric disorder affect the veteran's social and industrial capacity. All special studies or tests including psychological testing deemed necessary are to be accomplished. The examiner should assign a numerical code under the Global Assessment of Functioning Scale (GAF). It is imperative that the physician include a definition of the numerical code assigned. Thurber v. Brown, 5 Vet.App. 119 (1993). The diagnosis should be in accordance with the most recent edition of the American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorder. The entire claims folder and a copy of this remand must be made available to and reviewed by the examiner prior to the examination. 4. A social and industrial survey or investigation should be conducted. It should be ascertained if the veteran is working. Family members, former coworkers, members of the community and the veteran should be interviewed. The purpose of the survey is to obtain information upon which to assess the impact of the schizophrenia on the veteran's ability to secure or follow a substantially gainful occupation. 5. The RO should review the examination report and determine if it is adequate for rating purposes and in full compliance with this Remand. If not, the report should be returned to the examiner for corrective action. Following completion of these actions and, if the decision remains unfavorable, the veteran and his representative should be provided with a supplemental statement of the case and afforded a reasonable period of time in which to respond. Thereafter, in accordance with current appellate procedures, the case should be returned to the Board for completion of appellate review. No action is required of the veteran until further notice is issued. JOAQUIN AGUAYO-PERELES Member, Board of Veterans' Appeals The Board of Veterans' Appeals Administrative Procedures Improvement Act, Pub. L. No. 103-271, § 6, 108 Stat. 740, ___ (1994), permits a proceeding instituted before the Board to be assigned to an individual member of the Board for a determination. This proceeding has been assigned to an individual member of the Board. Under 38 U.S.C.A. § 7252 (West 1991), only a decision of the Board of Veterans' Appeals is appealable to the United States Court of Veterans Appeals. This remand is in the nature of a preliminary order and does not constitute a decision of the Board on the merits of your appeal. 38 C.F.R. § 20.1100(b) (1993).